patricia l. hale, md, phd, facp cmio, glens falls hospital and cto, adirondack regional community...
TRANSCRIPT
Patricia L. Hale, MD, PhD, FACPCMIO, Glens Falls Hospital and CTO , Adirondack Regional Community Health Information Exchange [email protected] www.pathalemd.com
Learning Objectives Impact of e-prescribing on patient safety
and reduction of medication errors What’s new Explore the training requirements for
physicians Explore the implementation differences
between a small medical practice and an RHIN
Source: The Institute of Medicine of the National Academies of Science (IOM).2006 Slide used by permission from SureScripts
7,000 Americans Die Annually From Preventable Medication Errors
1.5 Million Americans Injured Annually by Preventable Medication Errors
Physicians write
4.5 billion prescriptions
each year. . . .On Paper!
The Challenge of “Prescription Hand-offs”
• Illegible Handwriting
• Unclear Abbreviations and Doses
• Verbal Communication Among Physicians, Patients and Pharmacists
Over 4.5 Billion Prescriptions Written Annually… Less than 1 in 5 of Physicians Use e-Prescribing Only 20% of prescriptions are prescribed
electronically with 80% still handwritten Most electronic prescriptions are still sent by
FAX
Sources: eHealth Initiative, 2004 and: Center for Information Technology Leadership, “The Value of Computerized Provider Order Entry in Ambulatory Settings,” 2003.
National savings from universal adoption ofelectronic prescribing systems could be as high as $27 billion
Patient safety Between 1.5%-4.0%
prescriptions are in error with serious patient risk
Adverse drug events occur in 5%-18% of ambulatory patients
Quality of care - Compliance 20% of scripts are never filled Patient satisfaction is
decliningCost of errors: $2 billion / yearImpact on productivity* Physician practice: 3 hours
per day Pharmacy: 4 hours per day
(up to 1 call per Rx) Inefficient delivery
Illegible handwriting
Phone tag and fax tag
Patient waiting in the pharmacy
Illegible handwriting
Phone tag and fax tag
Patient waiting in the pharmacy
RxRx
Rx
823 million visits to physician offices in 20001
4 out of 5 patients who visit a physician leave with at least one prescription2
65% of the US population (91% of Medicare) use a prescription medication each year3
1) Pastor PN et. al. Chartbook on trends in the health of Americans. Health, United States, 2002. National Center for Health Statistics. 2002.2) The chain pharmacy industry profile. National Association of Chain Drug Stores. 2001.3) Agency for Healthcare Research and Quality. MEPS Highlights #11: distribution of health care expenses, 1999.
3.5 Billion Total Filled Prescription Transactions in 2003 increased to 4.5 in
2006
1.4 B
0.4 B
0.5 B 1.5 B
Refills
New Scripts
Renewals
Unfilled
Certified version typically a simple upgrade away
Extremely low awareness among install base
RxInterOp
150,000 Certified EMR Users
Practice Size
Best estimates for EMR adoption based on high
quality surveys (%)
All 24
Solo 16
Large* 39
*”Large” is defined as > 20 physician FTEs in one study with 39% adoption and >50 in two another studies with 47% and 57% adoption respectively.
Sources: Jha et al, Health Affairs, 10/11/06; MGMA, 2005; CDC/NCHS Nat’l Ambulatory Medical Care Survey, 2005; HSC Community Tracking Study, 2006; Forrester, 2003; SureScripts estimates, 2006. Slide used by permission from SureScripts
Ability to create a prescription electronically Ability to receive automated decision support during script
creation Medication lists and information Eligibility determination Formulary coverage from insurer including co-pay
information Prior authorization clinical decision support including Drug interactions, drug-
allergy, etc. Ability to send script electronically to pharmacy using standard
transmission messaging (NCPDP SCRIPT, ASC12) Ability to receive/authorize pharmacy initiated-renewals
electronically Ability to determine “fill status” as a measure of compliance
(medication history) Ability for pharmacy to process electronic script in their system
Slide used by permission from SureScripts
Prescriber eRx
Software
Pharmacy and PBM
eRx SoftwareSureScripts
Provides:New Rx, refills,
renewals, authorizations,
change Rx, Prescription history from pharmacies
ProxyMed and others
Medimedia and others
RxHub Provides: Eligibility, Formularies, medication claims histories
Prescribers Office staff
Min
ute
s p
er
da
y
(2006 Study: Brown University) Slide used by permission from SureScripts
PenPrint6%
Fax37%
EDI+
Decision Support
61%
Source: CITL Slide used by permission from SureScripts
Patient & Physicians
AccessMedical
Websites
Electronic Prescribing
Electronic Medical Records Systems
Better informed consumers
Gains in accuracy and connectivity enhance safety and efficiency
Integrated database allow decision support tools
Streamlined information retrieval: valuable for epidemiology
Population-based outcomes and cost information readily available to consumers, physicians, payers
Algorithm-driven medicine and decision making
Regional Health
Information Networks
National Health
Information Infrastructure
National Disease
Databases
“Evidence-Based”
Medicine
Increased Decision Support
40-80%7-20%
16-40% <5%
Patients:Patients: Increased safety, efficiency and compliance Lower co-pays
Pharmacies:Pharmacies: Increased efficiency, improved care, improved
patient satisfaction Payors/PBMs:Payors/PBMs:
Increased generic/formulary usage, efficiency, Rx compliance and prevention of ADEs (reduced costs)
Providers:Providers: Increased efficiency, improved care, patient
satisfaction and potential incentives (pay-for-performance)
Cost of buying, installing, implementing and supporting a system
Lack of reimbursement for costs, time and resources
Increased time to use the system = reduced productivity (initially)
Increased time required to review warnings, alerts and recommendations (long term)
Still not considered a routine standard of practice
In the past… But now…
Very few pharmacies were directly connected to physician practices
Over 95% of US pharmacies are connected into a single network and growing
Electronic communications meant faxesComputer applications can communicate directly with each other
Only half the problem was being addressed… writing new scripts
Renewals can be automated in addition to new scripts
Software didn’t support the workflows in the practice
Software integrates with existing practice systems and smoothes office workflow
There were few real benefits for most practicesMost practices will save physician and staff time as well as improve patient safety
There wasn’t a future path to additional benefitsCollaboration now available with payors on patient compliance and other future functions
Automation was being driven by a few Health Plans and small software vendors
State and nation-wide initiatives now occur involving all major stakeholders
Economic Incentives Grant and Loan Programs Reimbursement for Utilization Pay for Performance Malpractice Insurance Premium Reductions Healthcare IT Suppliers group discounts, etc Pharmacies or Transaction Brokers Defray Costs
Policy Incentives and Programs Accreditation (JCAHO 2005 Hospitals’ National Patient
Safety Goals, others in development) Employer Programs (Leapfrog and others) Medicare support for economic incentives DOQ-IT CCHIT certification of inpatient and ambulatory
EMRs Mandates ???
Voluntary program Mandatory National eRx Standards for Medicare
Initial standards 2005; Pilot program 2006, Final Standards 2009 Recommendations delivered by NCVHS
Information Requirements include Lower cost, therapeutically appropriate alternatives Interactive, real-time to the extent feasible
Encourages Physician Adoption: Permits use of appropriate messaging Modifies anti-kickback regulation for hospital, physician groups
and plan administrators to allow them to give out eRx hardware and training
Allows plans to pay-for-technology and pay-for-cost effective performance in Medicare Advantage Plans
$50MM of federal grant money in 2007 (but must be budgeted) Preempts State Laws contrary to the national
standards or those that restrict the ability to carry out the new law.
Progress-to-date Issued Notice of Proposed Rule-Making (10/05) Issued final rule naming foundation standards
(11/05) Pilot programs competed and reports submitted
(2/06)Deadline for Secretary to
develop ePrescribing Standards
Sept 1, 2005
Jan 1, 2006
Apr 1, 2007
Apr 1, 2008
April 2009
Launch 1-yr voluntary
ePrescribing pilot
program; plans can offer P4P
Evaluation results of
pilot program due to
Congress
Deadline for Secretary to finalize and
release standards
All Medicare providers
using ePrescribing must adopt
finalized standards
RAND – New Jersey BCBS NJ, Caremark mail order, Walgreen retail pharmacy
Brigham & Women’s Hospital - CareGroup Health system in Boston use in EMR and e-prescribing “Gateway” utility
Achieve – tech vendor for long term care industry in Midwest with it’s own pharmacies
Ohio University Hospital Health System and Ohio KePRO QIO - 300 hospital physician practices
Surescripts - with practices in Florida, Mass, Nevada, New Jersey and Tennessee with a variety of software vendor systems and assortment of chain and independent pharmacies
Med History – recommended to be included as ready for adoption. Main challenge is ensuring the data is collected and reconciled from a large number of sources to be sure history is complete.
Formulary and Benefits – recommended to be included as ready for adoption. Issues: Systems must adequately match patient to
health plan Payers vary in the level of information provided
making data difficult to interpret Should support real-time changes in patient
status as patient moves between benefit plans
Prescription Fill Status Notification – recommended to be included as ready for adoption. However many pharmacies do not currently have the ability to track patient pick-up status accurately and questionable prescriber demand for this if the info is already available in the med history.
Prior Authorization – NOT recommended for implementation – Limited experience at pilot sites to evaluate this function and there are work flow and other issues which suggest a need to have more work done to improve the standard.
Structured and Codified Sig - NOT recommended for implementation – needs additional work with reference to field definitions and examples as well as naming conventions and clarification of field use.
RxNorm – (standard for name, dose and form of drugs) – Not recommended for implementation – Dictionary standard requires further evaluation and refinement.
Recommended updates to SCRIPT v8.1 – Need to further refine the standard to be able to: update prescriptions without having to create a
new order, send a refill from the facility to the pharmacy
without physician intervention, update patient information outside the context of
prescriptions
Prescriber staff (“surrogate prescribers”) played a much more important role in the process than anticipated.
Never fully replaces need for paper-based prescribing
Causes a shift in pharmacy work flow Poor adoption and use of medication history Long term care site reported a reduction in new
prescription rate which may indicate reduction in accumulation of multiple medication
Not enough data yet on effects on safety or change in use of generic medications.
“Dedicated to improving patient safety by providing free electronic prescribing for every physician in America”
The National ePrescribing Patient Safety Initiative (NEPSI)
A Coalition of the Nation’s Most Prominent Technology Companies, Healthcare Benefit And Medical Provider Organizations
Slide used by permission from NEPSI
National Sponsors Technology Sponsors
Connectivity Sponsors
Search Sponsor
Health Benefit Sponsors
Slide used by permission from NEPSI
eRx NOW™ from Allscripts described as: Simple: Web-based E-prescribing Software
Easy To Install and update Easy Interoperability Custom search engine from Google Formulary information available
Safe Comprehensive Allergy and Drug Interaction
Checking Secure
Secure anytime, anywhere access Rigorous credentialing and authentication
The “ATM of Healthcare??”
www.nationaleRx.com
Slide used by permission from NEPSI
Slide used by permission from SureScripts
Slide used by permission from SureScripts
FormularyE-Prescribing Rx HistoryE-Refills Eligibility
Pharmacy Health Information Exchange™, operated by SureScripts®
Slide used by permission from SureScripts
EMReClinicalWorkseClinicalWorks, Inc.
EPDrFirst RcopiaDrFirst
EPScriptSureDAW Systems
EP/EMRMedManagerChartConnect
EPCommunity Health RecordCerner
EMRBondMedical, IncBond Medical
EMRChart Management SystemBMA Enterprises
EPInfoSolutionsBCBS/AL
EP/EMRAxolotlAxolotl
EMRathenahealthathenahealth
EMRASP.MDASP.MD
EP/EMReRx NOW™Allscripts/NEPSI
EP/EMRTouchWorks/ TouchScriptAllscripts
EMRHealthmatics® EMRA4 Health Systems
EligibilityFormulary*Rx History* E-RefillsE-Prescrib.System
TypeProductCompany
Slide used by permission from SureScripts
GoldRx certification status No longer based on just compliance to
standards Identifies which vendors are not just
testing and marketing interoperability but are truly delivering and committed to: Customer Education Proven Pharmacy Interoperability Advanced Medication Management Workflow Enhancements &
Demonstrable Expert Experience with Electronic Prescribing Process
Slide used by permission from SureScripts
The first products to achieve GoldRx certification announced in Feb 2007: TouchWorks
EHR(Allscripts) ChartConnect EMR Rcopia (DrFirst) NextGen EMR eScript (RelayHealth) Pocketscript (Zix)
Slide used by permission from SureScripts
Last Year: RI was #1, MA was #3, MI was #10, WA and NJ not on last years list and FL and VA were in last year’s Top 10
Slide used by permission from SureScripts
Created by the National Association of Chain Drug Stores, the National Community Pharmacists Association and SureScripts
Certification Commission for Health Information Technology (CCHIT)
CCHIT Certification EMR ePrescribing Criteria 2007 2008 2009Send an electronic prescription to pharmacy
l
Send a query for formulary information l
Send a query for medication history to PBM or pharmacy and import medication list into EHR
l
Respond to a request for a refill sent from a pharmacy
l
Receive medication fulfillment history l
Respond to a request for a prescription change from a pharmacy
l
Send a cancel prescription message to a pharmacy
l
Send electronic prescription to pharmacy including structured and coded SIG instructions
l
44
RxHub SureScripts
Source of Data Claims data from PBMs
Dispensed Drug Data from Pharmacies
Interoperability Model
Pass-through Repository
Details Included No sig Sig (unstructured)
Regional Coverage Plan dependent Pharmacy dependent
Pricing $$$ $
45
46
47
A4 Health Achieve Allscripts Athena Health Bond Medical Catalis Health Cerner DrFirst eClinical
Works eHealth
Solutions EmDeon/
WebMD EPIC Gold Standard H2H Solutions Health Vision
InstantDx
iScribe
MA Share
McKesson
MDAnywhere
MdOffices
Medical Info Sys
MedicWare
MedKeeper
MedPlus
Medport
NewCrop
NextGen
OA Systems
Phytel
Purkinje
Relay Health RxNT
SafeMed
Script IQ
ScriptRx
Scriptsure
Sequel Systems
SSIMED
STI Con
Synamed
Zix Corporation
Bold = in production
Health care professionals can register for an ICERx.org account at www.ICERx.org or call 1.888.ICERX.50 (888-423-7950).
During periods of emergency, licensed health care professionals who have registered on ICERx.org can login to the online prescription database, where they will have access to: Evacuee prescription history information and the
name of the provider who wrote the prescription and the pharmacy that filled it
Available patient clinical alerts, including drug interaction, therapeutic duplication and elderly alerts
Clinical pharmacology drug reference information, including drug monographs, interaction reports and the drug identifier tool
As of February 2nd, 2007 - 48 States and Washington, D.C. cleared for electronic prescribing
As of February 2nd, 2004 - 25 States cleared for electronic prescribing
Slide used by permission from SureScripts
52Not shown: HI: 42%; AL: 24%; As of November 9, 2006
Access to more than 160 million patient prescription information records via payers and PBMs, through the growing list of RxHub certified technology partners. Direct contracts with payers and PBMs represent additional access to more than 50 million patients.
An increase in transaction volumes of 50% from 29 million transactions in 2005 to more than 43 million transactions in 2006. These transactions were real-time requests for patient eligibility and benefits, formulary, and medication history information, made at the point-of-care in the ambulatory and acute care settings from clinicians across the United States.
A ten-fold increase in true electronic prescriptions, which includes the transmission of patient-specific clinical decision support information at the point of prescribing, to retail and mail order pharmacy locations of the patient’s choice.
No two medical practices are alike – evaluation of current processes is critical in determining best product and implementation plan
Physicians learn by apprentice model – be sure there is a physician champion
Evaluate requirements for physician training early and plan schedules to accommodate decreased productivity
Workflow is a critical factor in success
Staff roll in the prescribing process is a major influence on potential success and usually underestimated
Time for training and implementation should be maximized (consider vendor recommendations as a MINIMUM)
When implementation of electronic prescribing is through a regional health information network new issues arise which include:
Management of shared medication lists Management of shared problems lists Opportunity for aggregated medication
history data Increased concerns about secondary use of
prescriber data
More options for stand alone, certified EMR and information network based electronic prescribing products
Increased connectivity of pharmacies and PBMs Increased functionality to improve office efficiency
(electronic refills) Support for implementation through programs like
DOQ-IT and others Grant, P4P and other funding opportunities New educational material and resources are
available
“We tried dedicating this computer to deciphering our doctors' handwriting."
Cartoon by Dave Harbaugh
Contact me at: [email protected]
Web site with further information and links: www.pathalemd.com